Provider Demographics
NPI:1497883557
Name:HICKSON, DAVID GRAHAM (LCSWR)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GRAHAM
Last Name:HICKSON
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 LATONA RD
Mailing Address - Street 2:WATONA OFFICE CAMPUS BLDG B DAVD HICKSON LCSWR
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626
Mailing Address - Country:US
Mailing Address - Phone:585-234-0018
Mailing Address - Fax:585-697-2078
Practice Address - Street 1:550 LATONA RD
Practice Address - Street 2:WATONA OFFICE CAMPUS BLDG B DAVD HICKSON LCSWR
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-234-0018
Practice Address - Fax:585-697-2078
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR06262611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11409040OtherAETNA CAQH
11409040OtherCAQH
11409040OtherCAQH